Tabla 1.

Figura 1. A. Left coronary artery without significant lesions. Ectatic vessels. B. Large-bore ectati...

Figura 2. Thrombotic occlusion of a large-bore ectatic right coronary artery. B. Mechanical thromboa...

Figura 3. Angiographic follow-up at 18 months. Mild to moderate distal in-stent restenosis.

Introduction

Coronary angioplasty in large-bore vessels poses a technical challenge. In elective cases, the selected device should allow for optimal stent strut apposition to the vessel wall, so as to minimize the incidence of acute thrombosis and in-stent restenosis1-3.

In cases of ST-segment elevation acute coronary syndrome (STEACS), decision-making is against the clock due to myocardial ischemia. In these cases, facing such a technical difficulty can lead to suboptimal results, particularly when dedicated devices are not available2, 4, 5.

Clinical case

The patient was a 57-year-old man. His cardiovascular risk factors included type 2 diabetes, obesity, and a sedentary lifestyle, with no known history of cardiovascular disease or other relevant data. He was admitted to the emergency department due to an episode of oppressive precordial pain classified as functional class IV lasting 50 minutes, without any other accompanying symptoms. The electrocardiogram performed showed ST-segment elevation in the inferior and right-sided leads. The infarction protocol was activated, and the patient was referred to the Department of Hemodynamics for a coronary angiography with potential primary percutaneous coronary intervention (PCI). The patient was hemodynamically stable upon admission, without signs of heart failure or the need for vasoactive drugs.

The coronary angiography was conducted using a Tiger 5-Fr catheter (Terumo Corporation, Tokyo, Japan) through the right transradial access. The left coronary artery ostium was cannulated, revealing no significant lesions in the left main artery, which had a good bore, an ectatic left anterior descending (LAD) artery with no significant lesions, and a circumflex artery (CX) with no significant lesions. Next, operators cannulated the right coronary artery (RCA), showing a large-bore ectatic vessel (>6 mm) with thrombotic occlusion at the level of its mid-segment (Figure 1). Given the presentation, a choice was made for primary PCI on the RCA.

Figure 1. A. Left coronary artery without significant lesions. Ectatic vessels. B. Large-bore ectatic right coronary artery with acute thrombotic occlusion.

A Judkins (Boston Scientific, Massachusetts, USA) 6-Fr therapeutic catheter was advanced over a 0.035” J wire for RCA ostium cannulation without achieving adequate support; consequently, it was exchanged for an XB 3.5 (Cordis Corporation, Miami, USA) therapeutic catheter. The occlusion was crossed with a 0.014” Floppy (Choice, Boston Scientific, Massachusetts, USA) coronary wire, which was positioned distally in the RCA. Due to high thrombotic burden, an intracoronary bolus of a glycoprotein IIb IIIa inhibitor (tirofiban – Agrastat, Phateon, Greenville, USA) was administered, with continuous infusion started via peripheral access. Thromboaspiration was also performed with a Hunter (IHT - Cordynamic, Iberhospitex SA, Barcelona, Spain) catheter, successfully extracting the thrombus and restoring distal flow.

Given the large bore of the artery, operators decided to implant three X-POSITION S Stentys® (STENTYS S.A., Paris, France) self-expanding nitinol sirolimus-eluting stents that were 6 × 27 mm, 5 × 27 mm, and 5 × 22 mm, respectively, reaching an adequate angiographic result, with TIMI III flow (Figure 3).

The patient progressed favorably and was discharged after 48 hours on dual antiplatelet therapy (aspirin and clopidogrel).

At 18 months, he remained asymptomatic and a follow-up angiography showed that the vessel was patent, with mild to moderate distal restenosis (Figure 3).

Figure 2. Thrombotic occlusion of a large-bore ectatic right coronary artery. B. Mechanical thromboaspiration. C. Implantation of three large sirolimus-eluting self-expanding stents. D. Aspirated thrombus.

Figure 3. Angiographic follow-up at 18 months. Mild to moderate distal in-stent restenosis.

Discussion

Coronary ectasia (CE) is defined as an abnormal dilation of the vessel, associated with changes in its blood flow, leading to increased blood viscosity and procoagulant state. Unlike coronary aneurysm, defined as a focal dilation of at least 1.5 times the diameter of the adjacent normal reference segment, in these cases, dilation is diffuse. Various studies have observed that, in more than half of the cases, the affected vessel is the right coronary artery1, 2, 6 (Table 1).

Percutaneous revascularization in aneurysmal or ectatic arteries is associated with a lower success rate and a higher incidence of no-reflow and distal embolization. On the other hand, in post-implantation follow-up of patients who experienced an acute coronary syndrome where the culprit vessel had CE, the rate of in-stent thrombosis and myocardial reinfarction was higher, and so was the rate of significant restenosis, a fact that was ruled out clinically and angiographically at the 18-month follow-up, in this case2, 6.

One of the most relevant factors in achieving a successful coronary angioplasty is the proper selection of stent diameter, which is particularly challenging in cases of coronary ectasia. In this setting, self-expanding stents have shown a significant reduction in the rate of malapposition (self-expanding balloon stent, 0.07% vs. balloon-expandable stent, 1.16%), achieving a larger luminal diameter compared to balloon-expandable stents. Oversizing balloon-expandable stents to achieve an appropriate diameter for the ectatic vessel can compromise device structure, causing significant alterations to the drug-delivery scaffold and damage to the vessel wall. Due to their characteristics, self-expanding stents reduce the risk of malapposition. At the proximal segment level, this decreases the incidence of in-stent thrombosis while, at the distal level, it reduces the likelihood of vessel dissection, particularly when there is a mismatch in vascular diameter3, 7.

Conclusion

The resolution of an ST-segment elevation acute coronary syndrome through primary PCI often requires making complex decisions in difficult scenarios. The balance between minimizing myocardial ischemia time and achieving the best possible angiographic results can be affected by the anatomical characteristics of the treated vessel and the resources available for revascularization. Coronary ectasia is a challenging condition due to its diffuse distribution, particularly in highly dilated vessels. In this case, the use of drug-eluting self-expanding coronary stents proved to be an appropriate strategy with good long-term clinical and angiographic results, as confirmed at the 18-month follow-up.

1. Akram Kawsara, Iván J Núñez Gil, Fahad Alqahtani, et al. Management of Coronary Artery Aneurysms. JACC: Cardiovascular Interventions 2018;11(13):1211-23.

2. Takahito Doi, Yu Kataoka, Teruo Noguchi, et al. Coronary Artery Ectasia Predicts Future Cardiac Events in Patients With Acute Myocardial Infarction. Issue 12, Pages 2350-2355, s.l. : Arteriosclerosis, Thrombosis, and Vascular Biology , 2017, Vol. 37.

3. Erik C. L. Grove, Steen Dalby Kristensen, et al. Stent thrombosis: definitions, mechanisms and prevention. An article from the e-journal of the ESC Council for Cardiology Practice, 2007, Vol 5. N°32.

4. Borja Ibanez, Stefan James, Stefan Agewall, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018;39(2):119-177.

5. Jennifer S. Lawton, Jacqueline E. Tamis-Holland, Sripal Bangalore, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines - Circulation 2022;145:e18-e114.

6. Gokturk Ipek, Baris Gungor, Mehmet Baran Karatas, et al. Risk Factors and Outcomes in Patients With Ectatic Infarct - Related Artery Who Underwent Primary Percutaneous Coronary Intervention After ST Elevated Myocardial Infarction. Istanbul, Turkey: Wiley Periodicals, Inc, 2016.

7. Dario Pellegrini, Bernardo Cortese et al. Focus on STENTYS® Xposition S Self-Apposing® stent: a review of available literature. Catheterization and Cardiovascular Interventions. Future Medicine Ltd, 2016;15(3):145-159.

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